Failure to Prevent Accident Hazards and Ensure Resident Supervision
Penalty
Summary
Multiple deficiencies were identified in the facility related to accident hazards and inadequate supervision of residents. One resident with a history of cerebrovascular disease, major depressive disorder, and vascular dementia was admitted with orders and care plans specifying the use of a wheelchair pad alarm to alert staff when the resident attempted to get up unassisted. Despite these orders, the resident was observed on multiple occasions without the required wheelchair pad alarm, and had experienced falls, including one incident where the resident removed the bed pad alarm. Interviews with nursing staff and review of facility policy confirmed that the alarm was not in place as required, increasing the risk of falls and injury. Another resident with severe cognitive impairment and a history of falls was found to have a fall mat in place as ordered, but the bed wheel was positioned on top of the mat. This placement was confirmed by staff to potentially cause permanent indentations, reducing the mat's effectiveness in cushioning falls. Facility instructions and policy explicitly state that heavy objects should not be left on fall mats to prevent damage and maintain their protective function. A third resident, also at high risk for falls, was observed with a broken pad/tab alarm sensor cord, rendering the alarm nonfunctional. There was confusion among staff regarding responsibility for ensuring the alarms were operational, with nursing, maintenance, and central supply staff each providing different accounts. Facility policy and equipment manuals require daily testing and proper connection of alarms to ensure resident safety. Additionally, a resident was found with an individual packet of A&D ointment at the bedside, despite not being assessed as safe for self-administration of medication. Staff interviews and facility policy confirmed that such medications should not be left accessible to residents, as this poses a safety risk.